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ZONING OFFICE USE ONLY ZONING OFFICE USE ONLY <br /> Project includes development within: (check all that apply) <br /> AF-1000' of a lake or pond c'300' of lake, pond, river or stream '300' of a floodplain <br /> ❑ A floodplain ❑ 75' of a wetland ❑ A wetland ❑ The vegetative buffer zone <br /> :tit, Shoreland Water body: L_o P� Identification: Wa..1,1Y Sy DNR designated? ❑Yes ❑No <br /> ❑ Wetland ❑ Shoreland wetland ❑Inland wetland ❑Wetland <2 acres <br /> ❑ Floodplain FEMA map panel: 55025C Flood zone: <br /> ❑Floodway ❑Flood fringe CI General floodplain ❑Flood storage <br /> Lot <br /> jnxisting ❑ Existing non-conforming ❑New <br /> Impervious Surface Calculations <br /> Area(square feet): � Sq Ft <br /> Total Lot: I <br /> Within 300' of <br /> ordinary high water <br /> mark Existing Additional Proposed Post Development <br /> Lot 3� <br /> Primary building <br /> footprint <br /> Accessory building(s) <br /> Driveway <br /> Any other impervious <br /> Total impervious - 3 / c�- <br /> Percent impervious ?�� a Q <br /> Project meets shoreland standardes ❑No Shoreland zoning permit denied: ❑YeNo <br /> Additional Dane County permits needed: <br /> Shoreland Erosion Control Permit ❑ Shoreland Mitigation Permit ❑Variance <br /> ❑Floodplain development permit ,oning Permit ❑ <br /> Additional information required: <br /> STATUS: ❑ Shoreland zoning permit and/or zoning permit issued contingent upon other permits <br /> 'Shoreland z ing permit o hold for other permits <br /> Issued by��,1. ' i / Date 11 i 3 l <br /> Assistan Zoning Administrator " <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL Application.docx Version 1.1 Created 12272013 <br />